Preperitoneal Packing Research Articles

Secondary Angio-Embolization After Emergent Pelvic Stabilization and Pelvic Packing Is a Safe Option for Patients With Persistent Hemorrhage From Unstable Pelvic Ring Injuries.

Introduction: In patients with severe pelvic ring injuries, exsanguination still is the leading cause of death in the early post-injury phase. While mechanical pelvic ring stabilization and pre-peritoneal pelvic packing are mainly addressing venous bleeding, angio-embolization aims to control arterial bleeding. The goal of the present study was to evaluate the rate of postoperative angio-embolization after mechanical pelvic ring injury stabilization and pre-peritoneal pelvic packing. Bleeding sources detected in the angiography and the patient's outcome were investigated.Patients and Methods: Retrospective observational cohort study at a single academic level I trauma center, reviewing all patients with pelvic ring injuries admitted from 01/2010 to 12/2019. Patients with emergent mechanical pelvic ring stabilization (supraacetabular external fixator and/or pelvic C-clamp) and direct pre-peritoneal pelvic packing were further analyzed. Patients that underwent postoperative angio-embolization were compared with those that did not. All postoperative angio-embolizations were evaluated with regards to bleeding sources and type of embolization.Results: During the study period, a total of 39 patients required immediate mechanical pelvic stabilization and direct pre-peritoneal pelvic packing. Of these, 12 patients (30.8%) underwent a postoperative angio-embolization. The following vessels were identified as bleeding sources: superior gluteal artery (n = 6), obturator artery (n = 2), internal pudendal artery (n = 2), unnamed branches of the internal iliac artery (n = 3). A selective embolization was successful in 11 patients; in 1 patient, an unilateral complete occlusion of the internal iliac artery was performed to control the bleeding. Mean time from hospital admission to the surgical procedure was 52.8 ± 14.7 min and the mean time from admission to angio-embolization was 189.1 ± 55.5 min. The in-hospital mortality rate of patients with angio-embolization was 25.0% (n = 3). Of these, 2 patients died due to multiple organ failure and 1 patient due to severe head injury.Conclusion: Secondary angio-embolization after external pelvic fixation and pre-peritoneal pelvic packing was effective in controlling ongoing bleeding. The most frequently detected bleeding vessel was the superior gluteal artery, which is difficult to surgically address, further highlighting the importance of angio-embolization in the management algorithm.

Unplanned Reoperation Rate at a Government-Designated Regional Trauma Center in Gangwon Province

Purpose Determining appropriate ways to assess health care quality within the National Health Insurance System is of interest to both the Korean government and the medical community. However, in the trauma field, the number of indicators used to evaluate surgical quality is limited. Using data collected over 5 years at Wonju Severance Christian Hospital Trauma Center in Korea, this study aimed to determine whether the unplanned reoperation rate in the field of trauma surgery could be used to assess the quality of an institution’s surgical care. Methods In total, 665 general surgical procedures were performed at the Trauma Center in 453 patients with abdominopelvic injuries from January 2015 to December 2019. Data were collected from the Trauma Center’s data registry and medical records, and included information regarding patients’ demographic characteristics, the type of index operation, and the reason for unplanned reoperations. Results A total of 453 index operations were evaluated. The proportion of patients with an Injury Severity Score (ISS) >15 was 48–70% over the 5-year period, with an unplanned reoperation rate of 2.1–9.3%. Patients had an average ISS score of 17.5, while the average Abbreviated Injury Scale score was 2.87. Unplanned reoperations were required in about 7% of patients. The most common complications requiring reoperation were recurrent bleeding (26.9%), wound problems (26.9%), intestinal infarction (15.4%), and anastomosis site leakage (7.7%). The procedures most frequently requiring unplanned reoperations were bowel surgery (segmental resection, primary repair, enterostomy, etc.) (24.5%) and preperitoneal pelvic packing (10.6%). Conclusions The proportion of reoperations was confirmed to be affected by injury severity. Keywords: Wounds and injuries; Reoperation; Quality of health care

Management of Hemodynamically Unstable Pelvic Ring Fractures.

Hemodynamically unstable pelvic fractures are challenging high-energy traumas. In many cases, these severely injured patients have additional traumatic injuries that also require a trauma surgeon's attention. However, these patients are often in extremis and require a multidisciplinary approach that needs to be set up in minutes. This calls for an evidence-based treatment algorithm. We think that the treatment of hemodynamically unstable pelvic fractures should primarily involve thorough resuscitation, mechanical stabilization, and preperitoneal pelvic packing. Angioembolization should be considered in patients that remain hemodynamically unstable. However, it should be used as an adjunct, rather than a primary means to achieve hemodynamic stability as most of the exsanguinating bleeding sources in pelvic trauma are of venous origin. Time is of the essence in these patients and should therefore be used appropriately. Hence, the hemodynamic status and physiology should be the driving force behind each decision-making step within the algorithm.

Pelvic packing and angio-embolization after blunt pelvic trauma: a retrospective 18-year analysis.

Treatment of pelvic trauma related hemorrhage is challenging and remains controversial. In hemodynamically unstable patients suspected for massive bleeding, pre-peritoneal packing (PPP) with temporary external fixation (EF) and subsequent trans-arterial embolization (TAE) can be performed in order to control bleeding. In hemodynamically stable patients suspected for minor to moderate bleeding, primary TAE with EF may be performed. The goal of this study was to determine effectiveness and safety of both strategies. Retrospectively, patients that received treatment for pelvic trauma-related hemorrhage at two level 1 trauma centers located in the United States between January 2001 and January 2019 were evaluated. Both centers advocate subsequent TAE in addition to PPP and EF in hemodynamically unstable patients, and primary TAE in stable patients. Demographic and clinical data was collected and mortality, ischemic and infectious complications were determined. In total, 135 patients met the inclusion criteria. Of these, 61 hemodynamically unstable patients suspected for massive pelvic bleeding underwent primary PPP (45%) and 74 stable patients suspected for minor/moderate bleeding underwent primary TAE (55%). In total, 37/61 primary PPP patients underwent EF (61%) and 48 underwent adjunct TAE (79%), performed bilaterally in 77% and unselective by use of gelfoam in 72% of cases. Primary TAE patients received embolization bilaterally in 49% and unselective in 35% of cases. Exsanguination-related deaths were found in 7/61 primary PPP patients (11%). There were none among the primary TAE patients. Potentially ischemic in-hospital complications, of which one could be considered severe (gluteal necrosis), occurred more in patients that received bilateral unselective TAE compared to all other TAE patients (p=0.02). Primary TAE appears to be an effective and safe adjunct for (minor) pelvic hemorrhage in hemodynamically stable patients. Primary PPP followed by EF and adjunct bilateral unselective TAE with gelfoam appears effective for those suspected of massive pelvic bleeding. This unselective embolization approach using gelfoam might be related to (ischemic) complications. When considering the amount and severity of complications and the severity of pelvic trauma, these might not outweigh the benefit of fast hemorrhage control.

Refractory pelvic fracture-associated hemorrhage after preperitoneal packing: now what?

A male patient in his 50s presented after a high-speed motorcycle crash. On arrival to the trauma bay, his primary survey was intact with normal vital signs. He had an...

Resuscitative Endovascular Balloon Occlusion of the Aorta vs Pre-Peritoneal Packing in Patients with Pelvic Fracture

Pelvic hemorrhage is potentially lethal despite homeostatic interventions such as pre-peritoneal packing (PP), resuscitative endovascular balloon occlusion of the aorta (REBOA), surgery, and/or angioembolization. REBOA may be used as an alternative/adjunct to PP for temporizing bleeding in patients with pelvic fractures. Our study aimed to compare the outcomes of REBOA and/or PP, as temporizing measures, in blunt pelvic fracture patients. We hypothesized that REBOA is associated with worsened outcomes. We performed a 2017 review of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) and identified trauma patients with blunt pelvic fractures who underwent REBOA placement and/or PP before laparotomy and/or angioembolization. Propensity score matching was performed, adjusting for demographics, vitals, mechanism of injury, ISS, each body region-AIS, and pelvic fracture type. Outcomes were complication rates and mortality. A total of 156 patients (PP: 52; REBOA: 52; REBOA+PP: 52) were matched and included. Mean age was 43 ± 18 years, Injury Severity Score (ISS) was 28 (range 17-32), and 74% were males. Overall mortality was 42%. The 24-hour mortality (25% vs 14% vs 35%; p= 0.042), in-hospital mortality (44% vs 29% vs 54%; p= 0.034), and 4-hour pRBC units transfused (15 [9-23] vs 10 [4-19] vs 16 [9-27]; p= 0.017) were lower in the REBOA group. The REBOA group had faster times to both laparotomy (p= 0.040) and/or angioembolization (p= 0.012). There was no difference between the groups in acute kidney injury, lower limb amputations, or hospital and ICU length of stay among survivors. REBOA is a less invasive procedure compared with PP and is associated with improved outcomes. Further clinical trials are needed to define the optimal patient who will benefit from REBOA.

Resuscitative Endovascular Balloon Occlusion of the Aorta vs Pre-Peritoneal Packing in Trauma Patients with Pelvic Fracture

Asmar, Samer MD; Khurrum, Muhammad MD; Liang Tang, Andrew MD, FACS; Bible, Letitia MD; Kulvatunyou, Narong MD, FACS; Chehab, Mohamad MD; Hanna, Kamil MD; Joseph, Bellal MD, FACS Author Information

Consecuencias de la toma de decisiones terapéuticas con base en el resultado del FAST en pacientes politraumáticos con fractura pélvica

IntroductionFAST is essential to decide if trauma patients need laparotomy, but has a notably decrease in accuracy in patients with pelvic fracture.Our objective is to analyze the consequences of therapeutic decision-making based on the FAST results in trauma patients with pelvic fracture. MethodsDescriptive study that includes trauma patients older than 16 with a pelvic fracture admitted to the critical care area or who were fallecimiento. FAST result was compared with a true positive or negative value according to the results of laparotomy or abdominal CT. We recorded diagnosis and treatment of each injury and resolution of the case, detailing the cause of death, among all variables. ResultsOver the 13–year period, we included 263 trauma patients with pelvic fracture, with a mean ISS of 31 and mortality of 19%. FAST had a sensitivity of 65.2%, specificity of 69%, false negative rate of 34.8% and false positive rate of 30.9%. Hemodynamically unstable patients died twice as many stable patients (27% vs. 14%, p <0.05). Patients with positive FAST died more than negative FAST (43% vs. 26%); and 4 of 10 hemodynamically unstable patients who underwent non therapeutic laparotomy after presenting a false positive FAST died from hypovolemic shock. The mortality rate fell from 60% to 20% when preperitoneal packing was performed before angio-embolization of the pelvis. ConclusionFAST has low accuracy in polytraumatized patients with pelvic fracture. Patients with false positive FAST have higher mortality, which can be reduce notably applying a preperitoneal packing.

Military experience in the management of pelvic fractures from OIF/OEF

IntroductionPelvic fractures are a common occurrence in combat trauma. However, the fracture pattern and management within the most recent conflicts, i.e. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF),...

Worth looking! venous thromboembolism in patients who undergo preperitoneal pelvic packing warrants screening duplex

BackgroundVenous thromboembolism (VTE) in patients with major pelvic fractures who undergo preperitoneal pelvic packing (PPP) has not been investigated. We hypothesized that patients who undergo PPP are at high risk for VTE, thus early prophylactic anticoagulation and screening duplex are warranted. Study designAll patients requiring PPP from 2015 to 2019 were reviewed. Management and outcomes were analyzed. ResultsDuring the study period, 79 patients underwent PPP. Excluding the early deaths, 17 patients had deep venous thrombosis (DVT) and 6 had pulmonary emboli (PE); 4 patients had both DVT/PE. Overall mortality was 15%. Thirty-two patients underwent screening duplex within 72 h of admission and 10 were positive for DVT. ConclusionPatients with complex pelvic trauma undergoing PPP have a 23% incidence of DVT and an additional 8% incidence of PE. 31% of screening ultrasounds are positive. The overall mortality was 15%. With a high incidence of VTE in this patient population, we recommend screening duplex ultrasounds.

Effectiveness of kaolin-impregnated hemostatic gauze use in preperitoneal pelvic packing for patients with pelvic fractures and hemodynamic instability: A propensity score matching analysis.

We evaluated the effectiveness of kaolin-impregnated hemostatic gauze use in preperitoneal pelvic packing (PPP) for patients with hemodynamic instability due to severe pelvic fractures. Between May 2014 and October 2018, 53 of 75 patients who underwent PPP due to hemodynamic instability induced by pelvic fracture were enrolled. Their medical records were prospectively collected and retrospectively analyzed. QuikClot combat gauze (hydrophilic gauze impregnated with kaolin) and general surgical tape were used in 21 patients, while general surgical tape was used in the remaining 32 patients. As there were differences in the characteristics of patients between the hemostatic gauze (HG) group and control group, propensity score matching (PSM) was performed to adjust for age, sex, and lactate levels. After PSM, the clinical characteristics between the two groups became similar. There were no differences in the rates of mortality and hemorrhage-induced mortality between the two groups. However, the packed red blood cell (RBC) requirement for an additional 12 hours in the HG group was significantly lower than that in the control group (4.1 ± 3.5 vs. 7.6 ± 6.1 units, p = 0.035). The lengths of intensive care unit and hospital stays tended to be shorter in the HG group than in the control group (11.6 vs. 18.5 days, p = 0.1582; 30.8 vs. 47.4 days, p = 0.1861, respectively). The use of HG during PPP did not reduce hemorrhage-induced mortality, but did reduce the need for additional packed RBC transfusions in patients with hemodynamic instability due to severe pelvic fractures.

Modified unilateral inguinal incision preperitoneal packing in a patient with an unstable pelvic bone fracture with ongoing abdominal wall hemorrhage

Modified unilateral inguinal incision preperitoneal packing in a patient with an unstable pelvic bone fracture with ongoing abdominal wall hemorrhage

A patient with severe polytrauma with massive pulmonary contusion and hemorrhage successfully treated with multiple treatment modalities: a case report

BackgroundThe mortality rate is very high for patients with severe multiple trauma with massive pulmonary contusion containing intrapulmonary hemorrhage. Multiple treatment modalities are needed not only for a prevention of cardiac arrest and quick hemostasis against multiple injuries, but also for recovery of oxygenation to save the patient’s life.Case presentationA 48-year-old Japanese woman fell down stairs that had a height of approximately 4 m. An X-ray showed pneumothorax, pulmonary contusion in her right lung, and an unstable pelvic fracture. A chest drain was inserted and preperitoneal pelvic packing was performed to control bleeding, performing resuscitative endovascular balloon occlusion of the aorta. A computed tomography scan revealed massive lung contusion in the lower lobe of her right lung, pelvic fractures, and multiple fractures and hematoma in other areas. An emergency thoracotomy was performed, and then we performed wide wedge resection of the injured lung, clamping proximal to suture lines with two Satinsky blood vessel clamps. The vessel clamps were left in the right thoracic cavity. The other hemorrhagic areas were embolized by transcatheter arterial embolization. However, since her respiratory functions deteriorated in the intensive care unit, veno-venous extracorporeal membrane oxygenation was used for lung assist. Planned reoperation under veno-venous extracorporeal membrane oxygenation was performed on day 2. Since her respiratory condition improved gradually, the veno-venous extracorporeal membrane oxygenation circuit was withdrawn on day 7. She was transferred to the psychiatric ward of our hospital on day 75.ConclusionUtilizing multiple treatment modalities such as resuscitative endovascular balloon occlusion of the aorta, damage control surgery, transcatheter arterial embolization, and veno-venous extracorporeal membrane oxygenation with appropriate timing saves a patient with severe polytrauma with massive pulmonary contusion including intrapulmonary hemorrhage.

Pelvic Trauma: factors predicting arterial hemorrhage and the role of Angiography and preperitoneal pelvic packing.

(1) To identify the factors predicting arterial extravasation in pelvic trauma and (2) to assess the efficacy of preperitoneal pelvic packing (PPP) in controlling arterial hemorrhage. Institutional review board approved the retrospective study of 139 consecutive pelvic trauma patients who underwent angiographic intervention with or without prior PPP between January 2011 and December 2016. Patient demographics and presenting characteristics were recorded. Both groups of patients were combined for analysis of predictors for arterial extravasation using univariate logistic regression followed by multivariate logistic regression. Significance level was defined as p < 0.05. Forty-nine out of 139 patients had PPP prior to pelvic angiogram. Embolization was performed in 85 (61.2%) patients and the technical and clinical success rate was 100%. Sixty-nine (49.7%) patients had unstable Young-Burgess (Y&B) type fractures, of which 58% had arterial hemorrhage compared with 38.6% of those with stable Y&B fractures (p = 0.02). Of the patients who had PPP prior to angiogram, 28(57.1%) continued to have arterial extravasation on subsequent angiography. Unstable Y&B type fractures are independent predictors of arterial hemorrhage (OR 2.3, 95%CI 1.1 to 4.7, p = 0.02). Unstable Y&B type pelvic fractures are predictors of arterial extravasation. PPP alone is not effective for arterial hemorrhage control in pelvic trauma. Angiographic intervention remains a minimally invasive and definitive treatment of arterial hemorrhage from pelvic trauma. • Unstable Young-Burgess pelvic fractures are predictors of arterial hemorrhage in pelvic trauma. • Pelvic angiography and embolization should precede PPP wherever feasible.

Pre-peritoneal pelvic packing for early hemorrhage control reduces mortality compared to resuscitative endovascular balloon occlusion of the aorta in severe blunt pelvic trauma patients: A nationwide analysis

BackgroundEarly hemorrhage control after severe blunt pelvic trauma is life-saving. The aim of this study is to compare the efficacy and outcomes of pre-peritoneal packing (PPP) and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) with a subsequent hemorrhage control procedure to control life-threatening pelvic hemorrhage in trauma patients. MethodsA 3-year (2015–2017) retrospective analysis of the Trauma Quality Improvement Program (TQIP) was performed. All blunt trauma patients (aged ≥15 years) who underwent PPP or Zone 3 REBOA placement were included while deaths on arrival and transfers were excluded. Patients were matched on clinical characteristics using propensity score matching (PSM). Univariate analysis was performed to compare mortality, time to procedure, time in ED, transfusion requirements, complications rates, and ICU and hospital length of stay (LOS) amongst patient groups. ResultsOf 420 trauma patients, 307 underwent PPP and 113 REBOA. Patients had similar hemodynamics and ISS upon presentation, but PPP patients had a higher GCS (P = 0.037) and more blunt kidney injuries (P = 0.015). After PSM, 206 trauma patients were included in the analysis. There were no significant differences in blood transfusion, LOS, or major complications. Time to REBOA was shorter than time to PPP (52 vs 77.5 min; P<0.001) with longer time in ED (65 vs 51 min; p = 0.023). The 24-hour (32.4 vs 17.7%; P = 0.23) and in-hospital mortality (52.0 vs 37.3%; P = 0.048) were higher after REBOA. ConclusionPPP is associated with improved survival compared to REBOA placement. Delay in definitive hemorrhage control may provide a potential explanation, but causation remains unresolved. This data suggests that early PPP may offer a benefit over REBOA in the setting of hemorrhage after blunt pelvic trauma. Further, large, multi-institutional studies are warranted to support these findings. Level of EvidencePrognostic study, level III.

Scalpel or Sheath? Outcomes Comparison Between Pre-Peritoneal Pelvic Packing and Angioembolization for Definitive Hemorrhage Control After REBOA

Background: The role of angioembolization (AE) and pre-peritoneal pelvic packing (PPP) for pelvic hemorrhage control in the era of resuscitative endovascular balloon occlusion of the aorta (REBOA) has not been well described. Our aim was to investigate outcomes of PPP and AE after REBOA. Methods: Patients who received aortic occlusion (AO) at Zone 3 (distal abdominal aorta) plus PPP and/or AE at three high-volume REBOA centers between February 2013 and December 2018 were identified. Outcomes were compared between three groups based on procedures performed: REBOA with PPP only (RPPP), REBOA with angioembolization only (RAE), and REBOA with PPP and AE (RPPPAE).Results: Fifty-eight patients underwent REBOA at Zone 3; 37 RPPP, 13 RAE, 8 RPPPAE. Mean age was 45 ± 16 years, mean injury severity score (ISS) 35 ± 13, mean systolic blood pressure (SBP) pre-AO was 71 ± 19 mmHg, and post-AO SBP was 110 ± 34 mmHg. In-hospital mortality was 28%, with the majority of deaths occurring in the intensive care unit. Age, ISS, admission SBP, physiology on admission and at the time of AO, response to AO, admission hemoglobin, blood products transfused, and rate of local wound infections were not different between RPPP and RAE groups. Comparing RPPP to RAE groups, duration of AO was significantly lower in the RPPP group (45 + 34 vs 81 + 37 mins, p = 0.012), while rates of acute kidney injury (14% vs 46%) and distal embolism (8% vs 31%) were higher in the RAEgroup (p = 0.015, 0.04, respectively).There was no statistical difference in mortality between RPPP (22%) and RAE patients (39%), including on regression analysis controlling for duration of AO and ongoing CPR at the time of AO.Conclusion: Despite a longer duration of AO and higher rates of ongoing CPR at the time of AO in RAE patients, mortality rates are similar whether hemostasis is achieved after REBOA with pelvic packing or angioembolization. RPPP results in significantly lower systemic and local complication rates.

High incidence of surgical site infection may be related to suboptimal case selection for non-selective arterial embolization during resuscitation of patients with pelvic fractures: a retrospective study

BackgroundIn most institutions, arterial embolization (AE) remains a standard procedure to achieve hemostasis during the resuscitation of patients with pelvic fractures. However, the actual benefits of AE are controversial. In this study, we aimed to explore AE-related outcomes following resuscitation at our center and to assess the predictive value of contrast extravasation (CE) during computed tomography (CT) for patients with hemodynamically unstable closed pelvic fractures.MethodsWe retrospectively reviewed data from patients who were treated for closed pelvic fractures at a single center between 2014 and 2017. Data regarding the AE and clinical parameters were analyzed to determine whether poor outcomes could be predicted.ResultsDuring the study period, 545 patients were treated for closed pelvic fractures, including 131 patients who underwent angiography and 129 patients who underwent AE. Nonselective bilateral internal iliac artery embolization (nBIIAE) was the major AE strategy (74%). Relative to the non-AE group, the AE group had higher values for injury severity score, shock at hospital arrival, and unstable fracture patterns. The AE group was also more likely to require osteosynthesis and develop surgical site infections (SSIs). Fourteen patients (10.9%) experienced late complications following the AE intervention, including 3 men who had impotence at the 12-month follow-up visit and 11 patients who developed SSIs after undergoing AE and osteosynthesis (incidence of SSI: 11/75 patients, 14.7%). Nine of the 11 patients who developed SSI after AE had undergone nBIIAE. The positive predictive value of CE during CT was 29.6%, with a negative predictive value of 91.3%. Relative to patients with identifiable CE, patients without identifiable CE during CT had a higher mortality rate (30.0% vs. 11.0%, p = 0.03).ConclusionPerforming AE for pelvic fracture-related hemorrhage may not be best practice for patients with no CE detected during CT or for unstable patients who do not respond to resuscitation after exclusion of other sources of hemorrhage. Given the high incidence of SSI following nBIIAE, this procedure should be selected with care. Given their high mortality rate, patients without CE during imaging might be considered for other hemostasis procedures, such as preperitoneal pelvic packing.

The past, present, and future management of hemodynamic instability in patients with unstable pelvic ring injuries

Pelvic ring injuries presenting in hemorrhagic shock have historically had a mortality rate greater than 30%. To address this high mortality rate our institution has had a multi-disciplinary protocol for hemodynamically unstable pelvic ring injuries since 1993. In 2004, this protocol was revised to prioritize pre-peritoneal pelvic packing over angiography to rapidly control hemorrhage, reduce high-volume blood transfusions, and decrease the number of deaths from acute blood loss. This protocol has been successful in reducing deaths from hemorrhage by 30%. Despite the benefits of such a protocol, many trauma centers are not routinely stabilizing pelvic ring injuries or controlling pelvic hemorrhage. Subsequently, mortality rates remain high with a significant proportion of patients dying from acute blood loss. Trauma centers adhering to multi-disciplinary protocols that allow for rapid stabilization of the pelvis and simultaneous control of multiple sites of hemorrhage in hybrid operative suites are promising future directions for the management of patients with these lethal injuries.

Resuscitative endovascular balloon occlusion of the aorta in pelvic ring fractures: The Denver Health protocol

Patients presenting with hemodynamic instability associated with pelvic fractures continue to have very high mortality and surgeons continue to seek damage control strategies that may improve survival. Strategies usually require massive transfusion, immediate pelvic stabilization and another adjunctive maneuver's such as angioembolization or preperitoneal pelvic packing to prevent hemorrhagic death. One current intervention that has regained some popularity in lieu of resuscitative thoracotomy is the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). This requires some manner of femoral arterial access to insert a balloon into the aorta and increase central blood pressure (cardiac and cerebral perfusion) and control active pelvic bleeding. Based on several animal models and an increasing number of publications, many US level I trauma centers have now opted to use REBOA in carefully selected patients showing signs of near cardiac arrest from non-compressible torso hemorrhage. Description of the current advances in aortic occlusion using catheter-based technology in the setting of severe shock for non-compressible torso hemorrhage from pelvic ring fracture is the purpose of this report.

Preperitoneal Pelvic Packing Is Not Associated With an Increased Risk of Surgical Site Infections After Internal Anterior Pelvic Ring Fixation.

To investigate the risk of postoperative surgical site infections after plate fixation of the anterior pelvic ring subsequent to preperitoneal pelvic packing (PPP). Retrospective observational cohort study. Level I academic trauma center. Adult trauma patients with unstable pelvic ring injuries requiring surgical fixation of the anterior pelvic ring. Pelvic plate fixation was performed as a staged procedure after external fixation and PPP/depacking (PPP group; n = 25) or as a single-stage primary internal fixation (control group; n = 87). Incidence of postoperative surgical site infections of the pelvic space. Anterior pelvic plate fixation was performed in 112 patients during a 5-year study period. The PPP group had higher injury severity scores and transfused packed red blood cells than the control group (injury severity score: 46 ± 12.2 vs. 29 ± 1.5; packed red blood cells: 13 ± 10 vs. 5 ± 2; P < 0.05). The mean time until pelvic depacking was 1.7 ± 0.6 days (range: 1-3 days) and 3.4 ± 3.7 days (range: 0-15 days) from depacking until pelvic fracture fixation. Two patients in the PPP group and 8 patients in the control group developed a postoperative infection requiring a surgical revision (8.0% vs. 9.2%; n.s.). Both PPP patients with a pelvic space infection had undergone anterior plate fixation for associated acetabular fractures. These data support the safety of the PPP protocol for bleeding pelvic ring injuries due to the lack of increased infection rates after fracture fixation. Caution should be applied when considering PPP in patients with associated acetabular fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.